Protracting molars with or without TAD’S

From: allan sheridan [mailto:captainal_92865@YAHOO.COM]
Sent: Monday, December 07, 2009 10:25 PM
Subject: Protracting molars with or without TAD’S

I have over a 40 year period protracted10-15 second or first molars in to fully healed bone with fairly good results. The teeth moved very slow and very light pressure was used. Many times the general dentist did have to build up interproximal surfaces for adequate contact.

Today, I ask myself the question–how many of these patients would have been just as well off with bridgework or today implant/crowns??  The answer I think depends on the integrity of the adjacent teeth –do we still cut down healthy virgin teeth?? 

The patient should be given all the options as well as risks and rewards. Many times it is a decision between time and money.

Allan Sheridan DMD, MS 

Orange, California

2 responses to “Protracting molars with or without TAD’S

  1. I don’t know if there is a simple answer. I always have tried to look at local factors in addition to economics and risk/benefit. Unless the patient has an ideal site for protraction (ie no “necking” or atrophy), one has to ponder the wisdom of risking moving the tooth forward but having questionable contacts and likely periodontal compromise; especially if there is minimal or no other indication for prolongued orthodontic treatment. If both the molar and premolar are “virgin” then a single tooth implant seems like a reasonable solution. If restored, then bridgework. My hunch is that there are clinicians enamoured with the idea simply because it can be done more easily (but no more quickly) with the use of TADs or OBAs.

  2. It is always great to hear from Paul on any orthodontic subject. I particularly liked the comment “because it can be done more easily (but no more quickly) with the use of TADs”. Reminds me of a recent lecture by Baccetti in which he talked about class II correction and emphasized “it is the biology not the appliance” that is important.

    If I may add some additional thoughts:

    1. When you decide to extract lower second bicuspids, it is almost always due to either crowding or anterior protrusion. Part of the tx plan is to retract the lower anterior teeth to some extent and that closes part of the extraction site. Depending on the original problem, you might have 1/4 to 1/2 the extraction site left to close. In other words 2-3 mm per side.
    2. When you extract a lower deciduous second molar, either unilaterally or bilaterally, you are starting with 10-11 mm of space in the extraction site. That’s 40-50% more space to deal with than a typical bicuspid extraction site so now you are trying to close 5-6 mm of space after you eliminate the same amount of crowding or protrusion. That is a problem of a different magnitude.
    3. Sometimes we try to tx a prosthetic problem orthodontically. These are the cases in which the lower second deciduous second molar is failing or has been recently lost and there is nothing else wrong that would justify moving the anterior teeth distally. So the tx plan calls for the lower first molar to be moved forward 10 mm. That means TADs, FORSUS, or real implants in the retromolar area as Gene Roberts has talked about. Gene’s cases sometimes took 3 years to accomplish and, I think it is fair to say, that he sometimes lost some bone on the mesial of the molars. Once you talk about real implants in the retromolar area, why not real implants in the bicuspid area. Remember Gene was doing it to prove he could and for research reasons.
    There is a case now on Orthotown under “TADs for Protraction” that illustrates this type of case: 17 yr old (non-grower) where the ortho is trying to move the molar about 10 mm.
    http://www.towniecentral.com/Orthotown/SiteDefault.aspx
    4. Moving lower molars forward 10 mm with a TAD or with a FORSUS reminds me of the days in which people talked about treating clicking joints by using an anterior repositioning split to “recapture” the disk. After the disk was recaptured, you were left with a posterior open bite. This was then dealt with by using full braces to erupt the posterior teeth into occlusion and this would be what stabilized the mandible in a forward position. Lot’s of people talked about this approach but, to the best of my knowledge, no one ever showed a documented case with final records. There was one case published in the AJODO using this technique and the orthodontist said that the best he could tell was the mandible wound up in the same location it started at. That is not to say that the molars can’t be moved forward 3-4 mm but 10? Not likely.
    5. My best cases are the ones in which I did orthodontics and my colleagues did their own thing. When I try to do surgical cases with ortho only, I am rarely proud of the final result. Same is true I think with these prostho cases being treated orthodontically. We’ve all been bombarded over the last few years with “multidisciplinary tx” and this is the opposite of that.
    6. BTW, I’ve personally inserted 500+ screws so I am not negative on the concept but I am becoming more realistic on the results achievable.
    7. Most of my pessimism stems from doing the above on adults. There might be some hope in growing patients but no hope in non-growers.

    For those of you who might be interested, I copied a few pages from Graber, Vanarsdall and Vig from the chapter by Dr. Eugene Roberts in which he talks about bone physiology. I read that material in earlier editions of Graber and I am convinced that mesial movement of lower molars is best handled in France at Lourdes. I’ve placed a copy of those four pages (10.5 MEG) at

    http://public.me.com/orthodmd

    If for some reason, it does not load properly, email me and I will send you a copy. If you want to read the entire chapter but don’t want to buy the book, you can borrow books from the AAO or ADA library.

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